Reducing Maternal Mortality Among Women Aged 13-34 Years in Delhi, India.

Executive Summary

The increased rates of maternal mortality in India have been a serious public health issue. For a variety of reasons, women in India are more susceptible to developing reproductive complications and deaths during pregnancy and at birth. Although there are various reasons that are attributable to the increase in maternal mortality, unsafe motherhood tops the list. The effect of unsafe motherhood to the health and lives of women, their families, and to the community at large is tragic, owing to the fact that they are generally preventable. Over the past few decades, the government of India has led in the fight against maternal mortality and has set timely targets to achieve its goals. As such, the millennium development goal number five is to promote maternal health and improve its significance, including the reduction of maternal mortality. The National Rural Health Mission, the MATIND project, and the Indira Gandhi Matritva Sahyog Yojana are some of the programs that have been established with the aim of lowering maternal mortality through promoting and improving the accessibility and availability of health services, especially in the rural and remote areas.

India has been highly committed in lowering the rates of maternal mortality through launching and implementing various initiatives. However, in various states such as Delhi, it has been observed that the progress is rather slow. According to recent observations in the trends of lowering maternal mortality, there is a possibility that India will miss its millennium development target (Government of India Census, 2011). Indeed, the ratio of maternal mortality is relatively high and is approximated to be 178 losses of lives per 100,000 live births, as indicated by a study conducted by RGI between 2010 and 2012. To address the issue of high maternal mortality in Delhi and its environments, The New Safe Motherhood Program should be implemented. It is worth noting that if applied, The New Safe Motherhood Program will help India as a whole to achieve its millennium development target of reducing the rates of maternal mortality to less than a hundred in every 100,000 live births.

 Health Issue Overview/ Population Overview

Mortality during the perinatal period, at birth, and in early childhood rearing is potential threats to all women in their reproductive age across distance and space. The consequences and effects that unsafe motherhood has not only the lives and health of mothers but also for their families and communities is tragic and disastrous, mostly because they are preventable. Thus, governments across the globe have emphasized on the need to reduce the rates of maternal mortality and have set time limits of achieving it, and India has not been an exception. As a matter of fact, maternal mortality has been an indicator of the levels of effective health services, especially to the poor communities within a nation, and hence, acts as one of the factors to consider when determining the progress of a nation.

In India, the rates of maternal deaths have reduced over the past decades from 750 in the 1960s to 400 in the 1990s to about 300 in the 2000s. However, in some states such as Delhi, the levels of maternal mortality are still above the projected average. Indeed, this is a factor that has invited numerous researchers to study the causes and other factors that are related to higher rates in maternal deaths, especially in women aged 13-34 years. Various factors, including pregnancies during the adolescence period when the body has not fully developed, short intervals amid pregnancies, socioeconomic aspects, and accessibility of health centers as well as unsafe motherhood have been identified. Nonetheless, these may not reveal the correct and actual picture of the issue of maternal deaths owing to the reason that they are conducted in hospitals as opposed to both the hospital settings and the community (Lassi et al., 2010). In Delhi, for example, there are 929 designated slums, which comprise more than 40% of the Indian populace. The entire population of Delhi is covered by less than 25 health centers, less than 10 maternity homes, slightly above a 100 health posts. Therefore, this means that a maternity home covers 2 million people and there is a health center for every fifty thousand people. Each health post covers more than 10, 000 people. Of note is the fact that most of these health institutions lack proper facilities and equipment to give obstetric care in case of an emergency.

Due to the numerous demographic issues that affect the people of Delhi, various birth care and deliveries are carried out by traditional birth attendants, also known as ‘dais,’ who lack sufficient knowledge and skills. Hence, it indicates that obstetric care is relatively poor, which translates to the increased levels of maternal mortality in the area. In other words, the approaches that are being used to address this public health issue is fragmented as it mainly focuses towards promoting institutional deliveries and overlooks the broader framework of the issue within the community. Therefore, the Indian government needs to adopt policies that move away from the prototype of institutional deliveries to that aimed at promoting safe deliveries in both institutions and homes. Therefore, in addition to equipping the hospitals with the required obstetric equipment, the traditional birth attendants should also be trained to prepare them with the skills and knowledge required in this sector. Other issues that increase the public health issue of maternal mortality should be considered when deciding on the policy to implement. As such, if implemented, the New Safe Motherhood Program will not only be concerned with the improvement of institutionalized settings, but it will also work towards reducing other social aspects that contribute to the vulnerability of women aged 13-34 years.

Epidemiology

Similar to other parts of the world, the epidemiology of the public health issue of maternal mortality in India is well documented. In most cases, maternal mortality occurs among adolescent pregnancies and in mothers of low socioeconomic status. Maternal deaths are usually high during delivery and the first few weeks of the post-partum period. However, there are variations depending on the population’s demography. While some maternal deaths are attributable to direct foundations such as hemorrhage, infections, and hypertensive conditions, others are as a result of unsafe deliveries. From 1990 to 2010, maternal deaths reduced by almost 50%. However, the level at which the deaths are occurring is excessively high. Most maternal deaths are occurring in developing countries, including sub-Saharan Africa and India. Not only does the number of maternal deaths reflect the growth and development of a country, but it also shows the gap between the rich and the poor as well as the accessibility and inequities of health facilities and services. By 2013, it was estimated that in India, there were 178 maternal deaths per a hundred thousand live births (Government of India Census, 2011). In fact, these figures of maternal deaths do not clearly elucidate the disparities of maternal mortality rates in socioeconomic and demographic differences among Indian inhabitants. For instance, the ratio of maternal deaths in Assam was 328, while that of Kerala was only 66. Despite the fact that India has witnessed a 50% decline in the levels of pregnancy-associated deaths over the past two decades, studies show that currently, 120 mothers die of the pregnancy related complication on a daily basis in India. Therefore, this is a clear illustration that there is a need to fund for more programs with the intentions of lowering the rates of maternal deaths through encouraging safe motherhood.

The millennium development goal 5 requires that by the year 2015, the ratio of maternal mortality should have been reduced by ¾, which was not the case. Indeed, to achieve this goal, India should have reduced the levels of maternal deaths to 109 per 100,000 live deliveries. Although this was achieved in some states such as Kerala, which was 61 per 100, 000 live births, Maharashtra at 68 maternal deaths in 100,000 live births, and Tamil Nadu at 78 as well as Andhra Pradesh at 92 by 2013, various states of lower socioeconomic statuses such as Delhi were not anywhere near achieving their MDG by 2015 (World Health Organization., 2009). The major causes of the high rates of maternal morbidity and mortality in Delhi in women aged 13-34 years include adolescent pregnancies, eclampsia, hemorrhage, and anemia, as well as socio-demographic aspects, with obstetric hemorrhage being the major cause of pregnancy-related deaths at primary, secondary, as well as tertiary caregiving setups.

Risk Factors and Health Determinants

Deaths related to pregnancy in Delhi, India are profoundly entrenched in the risk elements associated with poverty, illiteracy and poor education, gender inequalities, and lack of accessibility to health facilities. On a regional perspective, more than 65% of people of low income are women. In addition, lack of education, low income, low caste, and poor educational attainment leave women dependent or at the mercies of their husbands and other male counterparts. Another risk factor of maternal mortality is illiteracy. The high levels of illiteracy in women hinder their capacity to know and understand the need for prenatal and post-natal care, importance of nutrition, family planning, and safe motherhood practices. Indeed, most of the women who have not gone to school often tops the list of individuals with least access to not only the primary healthcare during pregnancy but also obstetric care services in case of an emergency owing to the fact that they are usually attended by the ‘dais’ or the untrained traditional birth attendants.

In addition, most emergency obstetric care clinics are situated in the urban centers, which make them inaccessible to numerous numbers of women in the rural settlement schemes. Furthermore, illiterate women who get the opportunity of visiting healthcare providers reportedly indicate of facing discrimination and inadequate quality care as compared to those who are educated. Another risk factor is childbirth without assistance of skilled attendants. Studies have shown that most of child deliveries in India occur at home without the assistance of skilled attendants. In fact, only 40% of child deliveries in India occur in health facilities (Danel et al., 2011). Indeed, women who do not visit health facilities during their gestation period and at birth fail to receive vital information on the danger signs during childbirth and pregnancy time. Important to note is that they also fail to receive supplements such as iron-folic acid that enhance the well-being of their fetuses and themselves.

Another perilous factor of maternal mortality in Delhi, India is teenage pregnancies and marriages. Although teenage marriages remain illegal in the country, nearly 40% of girls below the age of 18 are given away in marriage by their parents. Studies have shown that the states with high rates of teenage marriages also show the highest rates of maternal deaths. Girls who get married in their teenage have little or no information regarding their reproductive health and issues. It is due to this reason that pregnancy-related deaths have been rampant among women aged 13-34 years. In fact, girls aged 13-19 are more likely to die during childbirth as compared to those aged 20-25. In addition, teenagers are less likely to air their views or negotiate with their husbands about sexual relationships and family planning. Consequently, young mothers often experience complications during and after birth, which at times result in death. In fact, one out of every three pregnancy deaths could have been averted if women are encouraged to use contraceptives.

Health Determinants

Lack of Accessibility to Obstetric Services

Delhi has over 900 slums and only a few equipped healthcare facilities to cater for the population. Inaccessibility of healthcare, especially during an emergency is an important determinant of the rates of maternal deaths. In addition, most women receive inadequate care services that lead to deaths at birth or during the post-partum period. Most women who do not receive antenatal care face wide range of birth complications that could be avoided. In addition, others receive inadequate antenatal care services as obstetricians fail to prioritize various preventive strategies that could go a long way in enhancing the health of the mother and the fetus.

Insufficient Blood in Blood Banks

In case of obstetric emergencies, lack of adequate blood for transfusion has resulted in mortality of mothers. The issue causes delays that could have been solved by ensuring its availability. In fact, lack of blood for transfusion has been one of the major causes of maternal mortality in India, with probable reasons being anemia, hemorrhage, and ante-partum hemorrhage.

Lack of Post-Partum Care       

Lack of care after childbirth has also been a leading cause of maternal mortality in India. Most maternal deaths take place during the post-partum period, with most of the care being highly inadequate even in hospital settings. Due to lack of this care, most women are discharged soon after they have given birth. Hence, their families are left to take care of them despite having no systems of follow-up after they have been discharged.

Lack of Transport and Referrals

There are inadequate designated ambulances and vehicles in hospitals in case of emergencies. Women face a wide range of challenges in their attempt to reach a health facility in case of emergencies. In addition, referral systems are also insufficient in India, which is a factor that causes women to die in the processes of seeking a facility. In some cases, some private health facilities may refuse to admit individuals, especially if there no funds to support the medical expenses.

Critical Analysis of Prevention Programs

In an attempt to reduce the levels of maternal deaths, various intervention programs have emerged. One of these programs is the Child Survival and Safe Motherhood program that was launched in 1992. It was developed and supported by the Indian government in collaboration with the United Nations Children Fund (UNICEF) and the World Bank. The program intended to promote both the survival of children as well as safe deliveries. Among its objectives, prevention of maternal mortality was one of its goals. Although this program had various clauses that could help reduce maternal mortality in India, it lacked specifications of some important details such as the work plan of auxiliary nurse midwife.

The National Rural Health Initiative is another program that has been implemented by the Indian government with the aim of reducing maternal morbidity. Not only has the program offered substantial steps in bringing the overall health to individuals living in the rural areas but also has made positive strides in lowering the levels of maternal mortality. Its focus is on institutional childbirth and setting up of deliveries of obstetric care in case of emergencies (National Rural Health Mission Framework for Implementation, 2005-2012).

Junani Suruksha Yojana (JSY) and Chiranjeevi Yojana (CY) are other programs that have operated for the past ten years. They were also designed to reduce pregnancy-related deaths through lowering financial barriers that may hinder accessibility to healthcare services during child deliveries. The JSY program awards mothers who give birth in a public health institution while the CY targets women who are susceptible to maternal deaths such as the low-status factions (Sidney et al., 2012).

Although the JSY program has seen an increase in childbirths in public healthcare institutions, it has not influenced the levels of mortality attributable to pregnancies. Indeed, the quality of care given to women under this program has been less than optimal due to its inability to offer emergency obstetric services and deficits of front birth assistants (Sidney et al., 2012). Additionally, the CY program that has targeted the most susceptible women has witnessed a relatively low percentage of beneficiaries. Indeed, this can be explained by the fact that information did not reach the intended group and their incapacity to get the required documentation prepared in time.

The programs and approaches that have been implemented in India in the attempt to lower the levels of maternal mortality are fragmented as they focus mainly on the health facility deliveries. In fact, before implementing a program, the Indian government and other concerned stakeholders should take note of other issues that contribute to the elevated rates of the public health issues, including poverty, teenage marriages and pregnancies, family planning, access to healthcare facilities, and transport in case of emergencies, as well as nutrition. In essence, these factors have remained blind spots during the decision-making processes of policies. In fact, experts, bilateral organizations, and funders have mostly determined the programs and policies aimed at reducing the rates of maternal mortality without putting into consideration the voice of activists and women of Delhi, India. If the Indian government has the intentions of exploring the heights of reduced maternal mortality, the state should change from the paradigm of healthcare institutionalized deliveries and focus on safe deliveries and motherhood through addressing all the issues that lead to maternal mortality. In essence, the adoption of the New Safe Motherhood Program will be a fundamental option.

Program Design

A hierarchy of officers ranging from program coordinator, public relations officer, finance executive, project manager, and the progress expert will administer “The New Safe Motherhood Program.” The program coordinator will oversee the goals of the NGO regarding reducing maternal mortality among women aged 13-35 in New Delhi, India through a well-organized system of implementation. The NGO seeks to collaborate with public and private healthcare providers in New Delhi to ensure that expectant mothers are given the right treatment in healthcare facilities to reduce the chances of death. Although he is the ultimate head of the program, the program coordinator will work in collaboration with a public relations officer, finance executive, project manager, and the progress analysis to realize the effective implementation of the program as well as to attain the goals of the same.

The program coordinator will be in charge of the overall operations of the program through which he will identify the areas of priority and direct resources accordingly. In addition, the program director will assign duties to the various field agents who will be assigned different areas within the larger New Delhi (Gupta & Sivaramakrishnan, 2010). Therefore, the coordinator will maintain records regarding the plans of the program, designated areas of operations, financial outlay, and the people assigned that role. In addition, the program coordinator will supervise all the program initiatives by personally visiting the facilities to access the situation on the ground. Through such an approach, the coordinator will be capable of understanding the actual progress of the implementation process through identifying gaps and seeking to address them.

Being a comprehensive program, a systematic mode of implementation is more favorable in the sense that the program will have priorities that will determine what is done first, as well as what follows. Secondly, there will be a specific focus on which areas are given priority. In the vast New Delhi region, there are disparities regarding the degree of maternal mortality. Therefore, there will be a prime focus on the areas greatly affected by the scourge. The program will first be launched in those areas of New Delhi that experience high maternal mortality among mothers of the aforementioned age group. The program coordinator will increase resource allocation and focus on the specified areas as a way of finding a solution to the problem. Although other areas will also be incorporated in the program, more focus, and resource allocation will be in the areas with severe maternal deaths.

The program will constantly update its approach and system to ensure that it effectively increases the quality of healthcare as a way of curtailing the rising maternal mortality in New Delhi. Through such a plan, the program will seek to improve prenatal care, antenatal care, as well as preventive measures towards a better maternal healthcare. Such mechanism not only boosts the ideals of the program but also increase the chances of survival for the young ones. It is obvious that the most affected age group falls between the ages of 13-34. Therefore, this aspect underscores the role of teenage motherhood in increasing the maternal mortality.

The program will have a specific focus on the aspect of increasing awareness on the dangers of teenage pregnancy and early motherhood on life. Such an awareness program endeavors to achieve two imperative outcomes, namely increase healthcare quality for young mothers as an antidote to maternal mortality and decrease the number of young mothers, particularly teenage mothers (Dutta, 2012). Due to the high risks caused by the teenage pregnancy on the life of the mother, the program will seek to educate society on how to avert such risks by decreasing the rate of teenage motherhood. Therefore, through the public relations officer and field managers, the program will educate the public on the best ways to reduce the growing trends.

The role of the government will be underscored by the pursuit of partnership between the NGO and the public health institutions. In addition, government statistics on the same will also be considered for purposes of understanding the problem and creating a solution. In addition, “The New Safe Motherhood Program” will involve spreading awareness regarding the program. As such, the public relations officer and project manager under the guidance of the program coordinator will execute the initiative. The goals of the plan will comprise of; spreading awareness about the goals and plans of the “The New Safe Motherhood Program,” increase the participation of members of the public, increase accountability, enhance social consciousness on maternal mortality, and create a fair ground for increasing the equality in access of maternal health services.

Program Outcome and Evaluation

The aim of this proposal is to seek funding for “The New Safe Motherhood Program” that will radically reduce the maternal mortality among women aged 13-34 in New Delhi, India. In fact, this is a health program intended to implement measures that will lead to the reduced rates of death among young mothers aged between 13-34 through spreading awareness, increasing quality of care, reducing bias and discrimination, as well as increasing effective healthcare governance. Therefore, the objectives of the program will comprise the following areas.

• Increasing the quality of maternal health services in New Delhi
• Cultivating equality regarding access to quality maternal health
• Enhancing good governance in healthcare
• Increasing public-private partnerships in healthcare
• Infrastructure development
• Increasing awareness

Evaluation

There is need for a safe motherhood program that will ensure that the death rate among mothers is drastically reduced. There is a problem regarding the high number of women dying in the course of pregnancy or birth (Kashyap, 2009). Indeed, this is mainly due to the poor quality maternal services. “The New Safe Motherhood Program” will ensure that the kind of healthcare services given to mothers is of high quality. Through focus on high-quality maternity care, guaranteeing equality regarding access to services, increasing awareness, infrastructure development, public and private sector partnerships, and enhancing good governance in healthcare this program endeavors to achieve a minimum rate of maternal mortality. Equality regarding access of health services will be very important since it affects New Delhi and India as a whole through the caste system. A thorough awareness program will cultivate the aspect of non-discrimination while providing healthcare services. Partnerships between private and public healthcare providers will also be crucial in attaining the underlying goals of the program.

Program Sustainability

“The New Safe Motherhood Program is inherently sustainable on account of several factors that comprise of proper planning, existence of efficient infrastructure in New Delhi, partnerships between private and private players, easily available channels of communication, ease of transport and the existence of an established community welfare policy in New Delhi.

Budget

The budget for “The New Safe Motherhood Program” will mainly cater for capital expenses, monthly fixed costs, and variable costs. The total sum of money required for the entire program is $25 million.

References

Danel I, Graham WJ, Boerma T. 2011. Maternal death surveillance and response. Bulletin of the World Health Organization. World Health Organization; 89:779–779A.

Dutta, D. K. (2012). Insight Maternal Mortality: An Indian Facebook. New York: Jaypee             Brothers Publishers.

Government of India. Census 2011[database online] New Delhi: Office of the Registrar General & Census Commissioner, India 2011 (http://censusindia.gov.in/)

Gupta, A. & Sivaramakrishnan K. (2010). The State in India After Liberalization: Interdisciplinary Perspectives. New York: Routledge.

Kashyap A. (2009). No Tally of the Anguish: Accountability in Maternal Health Care in India.    New Delhi: Human Rights Watch.

Lassi ZS, Haider BA, Bhutta ZA. 2010. Community-based intervention packages for reducing maternal and neonatal morbidity and mortality and improving neonatal outcomes. Cochrane Database of Systematic Reviews, Issue 11.

National rural health mission framework for implementation 2005-2012.  New Delhi: Ministry of Health and Family Welfare, Government of India.

RGI (2013) Special bulletin on maternal mortality in India 2010–2012. New Delhi: Office of the Registrar General.

Sidney K, De Costa A, Diwan V, Mavalankar DV, Smith H. 2012. An evaluation of two large scale demand side financing programs for maternal health in India: the MATIND study protocol. BMC Public Health; 12(1):699.

Sidney K, Diwan V, El-Khatib Z, De Costa A. 2012. India’s JSY cash transfer program for maternal health: who participates and who doesn’t–a report from Ujjain district. Reproductive Health. 24; 9:2.

World Health Organization (2009). Safer pregnancy in Tamil Nadu: From vision to reality, World Health Organization, Regional Office for South-East Asia, New Delhi.

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